1. Bolwell, Brian J. MD, FACP

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I used to be a busy clinician. I was, in fact, a very busy clinician for 25 years. Being in the clinical trenches was great. My clinical skills were well-honed in my area of expertise (bone marrow transplantation). I had significant clinical credibility throughout the organization, and I was known as a go-to doc. Covering the inpatient service for many weeks throughout the year was wearing, but, in general, it was highly rewarding.

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I remember during that time that I had a significant disdain for what I called "meeting doctors," those in leadership who were rarely in the clinical trenches and who spent most of their time in various leadership meetings throughout the day. I thought these meeting doctors were people who did not "get it" and whose time could be better used elsewhere, like seeing some patients.


So now I am a "meeting doctor." I still see some patients, but far fewer than I used to. Leading a cancer center is different. Instead of in the trenches, I now find myself in a lot of meetings. All leaders have lots of meetings. I highly value most of them, especially one-on-one meetings with various members of the cancer center, both physician and non-physician. I always learn stuff about the cancer center, or their careers, or about science, during those meetings.


Meetings are important for building consensus and making decisions. But there is not an abundance of literature about how to lead or use meetings effectively. In my experience, one of the keys is to provide a safe haven for open dialogue. The issue of psychological safety is extremely important. The best decisions are made when all participate, and when many opinions are offered. The only way to achieve psychological safety is to seek it out, and make it abundantly clear to all that you want to hear differing opinions, and there will never be retribution for those who provide a contrary perspective.


I recently read a short, excellent essay in the Harvard Business Review entitled "7 Strategies for Better Group Decision-Making" by Torben Emmerling and Duncan Rooders. The first point they make is to keep the meeting group small when you need to make an important decision. Larger groups tend to have a higher desire to preserve harmony and to prevent dissent. Additionally, larger groups tend to evaluate information that is consistent with pre-existing beliefs. When I read this, I immediately wanted to read the entire essay because these points resonated with me.


I have been in many meetings with a large group. Dissenting opinions are rare in these settings, and most of the conversation is dialogue from people agreeing with the leader's point. The larger the group, the more difficult it is to provide a different opinion. When you're the only person providing a different opinion, it usually doesn't feel very good. I know this from personal experience. You risk being viewed as not part of the group, or not being a team player, or being emotionally unintelligent, or worse. Smaller groups make it easier for all to share their opinions.


The next points made by the authors build on tactics to elicit differing opinions. They suggest choosing a heterogeneous group over a homogenous one, and appointing a strategic dissenter. The dissenter is tasked with acting as a counterforce to the group's consensus. They believe that having a contrarian will lead to better decision-making, and better outcomes. This also makes sense, and is aligned with the importance of psychological safety.


Indeed, in Patrick Lencioni's excellent book, The Five Dysfunctions of a Team, his first two dysfunctions are a lack of trust and a fear of conflict. He strongly believes that a willingness to disagree, and to have healthy conflict, is essential for a well-functioning team. Therefore, having a team member be assigned the role of dissenter will insure conflict that will likely lead to a deeper discussion.


The essay by Emmerling and Rooders provides three suggestions of how to deliver a dissenting opinion. Focus feedback on the strategy, not on the individual; express comments as a suggestion, not a mandate; and express feedback in a way that shows that you appreciate the individuals working towards your collective goal. These suggestions highlight the importance of aligning impact with intent. When providing differing opinions, one's intent is generally noble-you are trying to elevate the dialogue and come to a better decision.


But if you are too blunt, or too personal, with your feedback then your impact will be quite different. You will be viewed in a negative light and lose any potential positive impact. This has been an issue that I have historically struggled with. I wish I could take back some of my dissenting feedback because I know that sometimes my impact totally negated my intent. This has been a hard won lesson for me, and it's a very important lesson to learn.


Another excellent point raised by the authors is to avoid an over-reliance on experts in meetings. While experts may be able to add useful information, the essay states that "blind trust in expert opinions can make the group susceptible to biases and distort the outcome." I agree. Far too often have I seen groups cave to the opinion of a so-called expert when more data from frontline employees about the issue in question would be more useful. In general, the knowledge of the people most familiar with the topic at hand is more important.


So, for those of you who are leaders and lead meetings, remember some simple points. If you need to make an important decision, keep the meeting size small. Whether you are leading or attending a meeting, remember that healthy conflict is essential for the best decisions. Reward, rather than punish, those who offer differing opinions. When offering another opinion, be respectful to all and focus on ideas and not on individuals. Finally, have confidence that your team will arrive at a good decision using their knowledge and skills, and avoid an overreliance on experts.


And it's a good idea, no matter what your leadership role is, to continue to see patients in clinic. It is rewarding, enjoyable, and helps when replying to those people who accuse you of not "getting it."


BRIAN J. BOLWELL, MD, FACP, is Chairman of the Taussig Cancer Institute and Professor of Medicine at the Cleveland Clinic Lerner School of Medicine. Cleveland Clinic is a top 10 cancer hospital according to U.S. News & World Report.


Straight Talk: Today's Cancer Centers

Brian J. Bolwell, MD... - Click to enlarge in new windowBrian J. Bolwell, MD, FACP. Brian J. Bolwell, MD, FACP